Our Funding Priorities

FSH Society research and fellowship grant awards provide vital startup funding for investigators in FSHD and research projects on FSHD. The fellowship program allows innovative and entrepreneurial research to develop and ultimately attract funding from large funding sources such as the US National Institutes of Health (NIH). Without the FSH Society research and fellowships program, many key initiatives in FSHD research might never have had the chance to begin. Well over 300 peer-reviewed papers have been published by FSH Society-funded researchers.

2018 Research Priorities

Trial Tool Kit. While drug development pipelines are beginning to produce candidate drugs, the trial tool kit needs to be completed. Evidence was presented that MRI STIR positivity correlates well with DUX4 target gene expression but this needs further refinement and to be reproduced. MRI directs to active disease processes but longitudinal studies are needed. Uniform definitions for (interpretation of) MRI imaging need to be established by the community. In the cardiac field stress tests are informative, which may also be explored in FSHD. Ultrasound is not a priority as it is hard to standardize between users, although does have the advantage of being lower cost and higher throughput, and may be useful earlier in the disease process. Electrical impedance myography may correlate to changes in muscle structure but its sensitivity to changes in muscle over time still needs to be determined The tool kit comprises biological and non invasive biomarkers and clinical outcome assessments which will be important for drug approvals.

Biological Biomarkers. The search for biological biomarkers need to be continued. While DUX4 target genes in the muscle may be better targets than DUX4 itself, several efforts are ongoing including RNAseq and proteomics studies, which also point towards suppression of PAX7 target genes as a potential FSHD biomaker. Peripheral serum markers for FSHD are preferred due to their easy assessment from blood samples. Caution should be taken to avoid as many potential confounders as possible.

Clinical Outcome Assessments. Strength, function and functional tests are relevant outcome measures, likely for later phase clinical trials. . Non-invasive or peripheral serum markers may also facilitate trial recruitment. Studies into these COAs preferably need to be done in multi-center context such as the FSHD clinical trial research network, or through international partnerships. Video measures are experimental and need further studies. Home devices, such as activity monitors, allow to follow patients longitudinally, for example in training trials. Patient reported outcomes are in development and will be important ultimately for clinical trials.

Alternative/complementary therapies. Focus is currently on reducing DUX4 expression/function by various means, but therapies that also ameliorate some of the major pathological drivers in FSHD, and/or augment muscle repair, may be quicker to clinic and improve quality of life, while DUX4-targeted therapies are being developed.

2) Pathophysiology

DUX4 With Regard to Fibrosis, Inflammatory Infiltrates and Fatty Infiltration. There is a gap between basic (DUX4) knowledge and clinical observations that need to be filled. It is unclear how assumingly sporadic, barely detectable expression of DUX4 results in generalized muscle weakness and wasting. Investigations in downstream consequences such as fibrosis, inflammatory infiltrates, oxidative stress, repair/regenerative response and fatty infiltration are warranted as these are often targets of therapy in other MDs as well. Studies in animal models may accelerate studies into these downstream pathways.

Temporal Analyses of Models. A number of animal models have been generated and there are more in development. All models have their utility and limitations. It is likely that these models may give us clues into what happens in patients and studies should focus on temporal analyses of these models to capture aspects of the disease over time. The models are also important for therapeutic studies. Imaging may aid temporal studies to define the order of events. Non-human primate models are not considered a priority due to cost and ethical issues?

Novel Models for Other Aspects. Novel models are likely necessary to capture other aspects of the disease. One example is to express mouse Dux in mice, as, although DUX4 and mDux have diverged considerably, there is large functional overlap between both proteins. Other examples are to continue investing in cellular models such as stem cells, iPS cells, organoids / organs-on-a-chip.

3) Molecular Mechanisms

Mechanisms of DUX4 Pathology. While expression of DUX4 is considered the cause for FSHD, the exact molecular mechanisms of DUX4 pathology are only partly understood. Studies of DUX4 and mDux in cellular and animal models are also necessary to understand why cells die from DUX4. Temporal studies are necessary to capture the heterogeneity and order of events. Caution should be taken with respect to endogenous versus overexpression, primary versus immortalized cells, and origin of the muscle biopsies need consideration.

DUX4 Functionality. Posttranslational modifications of DUX4 may affect is function, co-factors need to be identified and studied and its cellular localization and functionality should be further explored in the context of FSHD pathophysiology. Its role as transcription factor, also in relation to PAX3/PAX7, warrants further investigation. Most studies have focused on pathways that are activated by DUX4, and relatively few studies have addressed those genes and pathways that are suppressed. Roles of DUX4, in addition to being a transcription factor, are relatively understudied.

DUX4 Native and Conserved Function. The natural distribution and regulation of DUX4 expression should be studied. DUX4 is expressed at cleavage stage embryos but little is known about the regulation of DUX4 during development and which tissues express DUX4, as well as its (lack of) toxicity in those tissues. The distribution of DUX4 in FSHD muscle is not known, nor how it correlates with clinical and pathological aspects of FSHD muscle, nor at the preclinical level.

4) Genetics and Epigenetics

Harmonization of Genetic Testing. New diagnostic techniques are available, including those for prenatal or preimplantation diagnostics. While current DNA diagnostics is accurate, there remains a continuous need for harmonization and improvement, also in view of future trials. New technologies may aid this effort and allow for identification of new disease mechanisms, although it remains to be determined if new strategies are as cost- and time-efficient as current standards.

Disease Continuum and Genotype Classification. While for trial participation genetic confirmation is mandatory, the terms FSHD1 and FSHD2 need to be reconsidered as to prevent potential exclusion of FSHD2 patients from future therapies. The terms FSHD1 and FSHD2 have an historical basis but recent studies show that both are the result of the interaction of at least two genetic variables: the number of D4Z4 units on a 4qA permissive haplotype and variations in genes, such as SMCHD1, that modify the epigenetic repression of the D4Z4.

Understanding Drivers of Clinical Variability. Continuous efforts are necessary to increase our understanding of (the genetic and epigenetic basis) of clinical variability. Data presented at the workshop suggest that 50% of variance is familial, but that this differs between muscle groups varying from 30% in the facial muscles to 1% for upper extremity. Suggests different vulnerability to DUX4 e.g. there is 50% familial contribution to clinical variability of which 1-30% comes from D4Z4 repeat size. Genome wide studies in large patient cohorts may facilitate identification of modifiers, such as SMCHD1.

Role and Effects of Modifiers. The role of modifiers need to be better understood. We need to increase our ability to type the function of variants of these modifiers such as SMCHD1 and DNMT3B. Mutations in both disease genes can result in very discordant phenotypes (SMCHD1: FSHD and BAMS; DNMT3B: FSHD and ICF), but the cause for this discordance in not understood. Other modifiers are likely to exist and additional efforts are necessary to identify these genetic, epigenetic and non-genetic modifiers.

Please click on the links or drawers below to read previous research priorities documents.

Research Priorities for 2017

General areas of interest

General areas of interest include—tissue, cell and molecular biology studies of FSHD, the development of animal models for FSHD, biomarkers and outcomes measurements and clinical trials readiness. Proposals are sought for research that helps with understanding of the genetic, pathophysiological, neuromuscular and developmental mechanisms of the disease. Further, there is interest in the development of cell, small-molecule and gene therapy, genomic engineering technologies and other therapeutic programs that may arise from that understanding.

Specific areas of interest

Specific areas of interest as highlighted in the FSH Society’s 2016 annual research consortium include:

Molecular mechanisms (understanding genetic toxicity in FSHD; Understanding Dux4 and how to silence it. How to silence the RNA; understanding what real pathophysiology is in FSHD; studying relationship to other markers and correlation between the expression and activity, transcriptional activity of DUX4).

Genetics and epigenetic (studies that focus on the uniformity in the genetic testing and the subgrouping of patients as so far as that is possible; understanding of the epigenetic regulation of the repeats helps us to better understand the disease process and the disease mechanism; Modifiers of the disease mechanism).

Models (research that helps focus to ensure that we are measuring the same kinds of things, that it does translate into a usable tool for our therapeutic industry; development, characterization and use of animal models—whole animal; mice; fish; pig and mammal; emphasis on cellular models; research on models to help develop precisely how you deliver, how you formulate, how you get the conceptual entity to the effective therapeutic use of the entity requires something that you can test).

Summary of Priorities Discussion, November 10-11, 2016, FSHD International Research Consortium and Research Planning meetings

More than 125 scientists, clinicians, biotech and pharmaceutical company representatives, advocates and patients from throughout the world gathered at the 2016 FSHD International Research Consortium and Research Planning meetings in Boston on November 10-11, 2016 to update each other and to discuss their latest findings and ideas on facioscapulohumeral muscular dystrophy (FSHD) research. The meeting was co-chaired by David E. Housman, PhD (FSH Society Scientific Advisory Board Chairman & Massachusetts Institute of Technology, Cambridge, Massachusetts), Stephen J. Tapscott, MD, PhD (Fred Hutchinson Cancer Research Center, Seattle, Washington), Silvère van der Maarel, PhD (Leiden University Medical Center, Leiden, the Netherlands), and Kathryn Wagner, MD, PhD (Kennedy Krieger Institute & Johns Hopkins SOM, Baltimore, Maryland). Daniel Paul Perez, FSH Society, Lexington, Massachusetts served as the organizational chair.

The goal of this meeting is to integrate clinical and basic FSHD research, explore and verify the complex disease mechanism and various features of FSHD, and to follow up on considerations to move into the development of potential treatments for FSHD, and to prepare the community for clinical trials. All volunteer agencies working on FSHD were invited by the organizers and encouraged to attend. This meeting is organized by the FSH Society and sponsored by Acceleron, Association Française contre les Myopathies (AFM), aTyr Pharma, BioMarin, Cytokinetics, Facio Therapies BV, FSH Society, Fulcrum Therapeutics, Genea Biocells, Genomic Vision, Genzyme / Sanofi, Idera Pharma, Mouse Specifics, Muscular Dystrophy Association, Muscular Dystrophy Campaign (UK), NIH NICHD UMass Senator Paul Wellstone MD Cooperative Research for FSHD, Quintiles, Sarepta, Ultragenyx. We thank our sponsors for their generous financial support.

Impressive scientific progress has been made in recent years and months in our understanding of the disease. This is a forum that allows at a critically important time the community to convene and discuss new data and advances in FSHD; discuss strategies to verify and independently corroborate the findings; discuss focusing efforts and resources in the preclinical gap and translational phase of research; improve diagnostic techniques and criteria for FSHD; and consider and evaluate with industry how to move forward with new and existing therapies for the disorder.

On Thursday, November 10, the organizers began the meeting by reviewing the last years’ priorities and the follow up on these priorities as defined by the FSHD community in the calendar year 2016. There was a general consensus that every year this priority list gains importance as there is an increasing response from the community to the priorities formulated during the former meeting as evidenced from publications and presentations. This review was followed by a series platform sessions reviewing the latest advancements in 1.) clinical studies; genetics & epigenetics, 2.) molecular mechanisms, 3.) models, and 4.) therapeutic studies. Each platform session included presentations selected from pre-submitted abstracts. Sufficient time was allowed after each of the four platform sessions, each moderated by two distinguished scientists, whose role was to provide a stimulating overview of the topic and facilitated discussion. The day was concluded with an assembly session including a review of the presentations of the day and providing information to the attendants about the next day’s program. There was ample time to review and further discuss the latest developments at the posters.

Friday, November 11 was solely dedicated to the discussion and planning session, and included several sessions chaired and moderated by Drs. Michael Altherr (LANL, Los Alamos, New Mexico), Housman, Tapscott, Van der Maarel, Wagner and Mr. Perez.

Over the two days, researchers revisited the prior year’s priority areas identified, discussed what we have achieved, evaluated the gaps that need to be addressed, and listed areas where we need to focus and invest intellectual, scientific and financial resources. By the end of day two the group identified whether any of last year’s priority areas should be changed or be modified, and outlined a new list/set of mutually agreed upon priority areas to be considered. The meeting was a working meeting with experts, developing future plans in the context of what we know now. It was a very successful workshop with a positive, constructive and collaborative atmosphere where new and unpublished findings were communicated to the audience, and with excellent interaction between all participants.

From these discussions and analysis of transcripts of the meeting the following final listing of items, areas and priorities:

Statement of FSHD Scientific/Research Priorities 2016-2017
By consensus of the 2016 FSHD International Research Consortium

1. Clinical and therapeutic studies

There is a need for surrogate outcome biomarkers now that trials are becoming reality.

“Think a little bit about the issues that are posed by when therapeutic ‘A’ is actually in use how it might impact on the design and implantation of clinical trials. For Huntington’s Disease, clinical studies which use the UHDRS, the Universal Huntington’s Disease Rating Scale, rely heavily on movement. So that in fact if the use of tetrabenazine, which inhibits movement, is now allowed into the clinical trial, which may have to be, because it’s an approved therapeutic which has become the standard of care, now what you’ve done is to dramatically diminish the dynamic range that is available to your therapeutic.”

“So all of these outcomes discussed are going to become increasingly important as we move through the clinical development process, we need good data from them, as we can’t really convince regulators that these are good outcome measures in the clinic that are clinically meaningful and should be approvable. The more people that start using these measures, the better, and, obviously, in a nicely longitudinal way, that’s even better.”

II. Genetics and epigenetics

Need to focus on the uniformity in the genetic testing and the subgrouping of patients as so far as that is possible for trial readiness.

Further understanding of the epigenetic regulation of the repeats helps us to better understand the disease process and the disease mechanism and to identify therapeutic targets.

The search for modifiers of the disease mechanism needs to be continued as this can explain variability and identify new therapeutic targets.

Consistent measures of (epi)genetic changes are needed.

Highlighted excerpts from group discussion:

“Consider Request for Applications (RFA) from funding agencies related to one or more these priorities. Consider Sub-meeting(s) that certainly addresses each of these areas, sometime in the next 7 or 8 months. Essentially the establishment of a central equivalent of World Anti-Doping Agency (WADA) for the Olympics or something like that so that uniformity in the genetic testing is achieved and the sub grouping of FSHD patients can be done, done under uniform conditions.”

III. Molecular mechanisms

Need to understand genetic toxicity in FSHD. There is a gap in our knowledge between DUX4 cellular toxicity and pathophysiological processes in FSHD.

We need to understand the regulation and identity of DUX4. We need to know how to silence it, and how much to silence it.

Refine relationship to other markers and correlation between the expression and activity, transcriptional activity of DUX4 with some of the markers that we currently have.

Highlighted excerpts from group discussion:

“A lot of consensus that the expression of DUX4 probably its activity in the nucleus mediated through binding of the DNA possibly through its transcriptional activity is really the major cause of the disease. So there’s consensus if you knew how to epigenetically silence it, silence the RNA, silence the transcriptional activity that’s a good process.”

“Need to open big black box in terms of what the real pathophysiology is, is it transcriptional toxicity from inducing apoptosis, is it RNA toxicity, protein toxicity — that box really intellectually needs to be filled in. It may not need to be filled in to continue at present with developing therapies – but none-the-less this understanding is critical and essential.”

“Relationship to other markers. The next priority is to really start to correlate between the expression and activity, transcriptional activity of DUX4 with some of the markers that we have, how do the molecular markers correlate with disease muscle, how does the MRI correlate with the markers, and how can we measure disease progression in a mechanism that does not require years long functional assays, but might be focused to a specific marker or a specific muscle group.”

IV. Models

There is no ideal model; each model will serve its own needs.

Create a focus to ensure that we are measuring the same kinds of things, that it does translate into a usable tool for our therapeutic industry.

Establish meetings of the consortium of laboratories that are working on mouse/animal models.

Need for further development, characterization and use of variety of animal models.

More emphasis on cellular models (e.g. iPSC) — all aspects of all models.

Highlighted excerpts from group discussion:

“Need to create a nucleating focus to ensure that we are measuring the same kinds of things, that it does translate into a usable tool for our therapeutic industry brethren to ensure that these things can move as quickly as possible into testing paradigms in that way.”

“We need to consider all aspects of all models. Cell-based, again, are the kinds of things that lend themselves to high throughput assays. Our therapeutic industrial partners might look to engage in those kinds of high throughput assays using a variety of cells. If stem cells, either induced or embryonic, were useful in this. Consideration of this potentially being a developmental phenomena with a later in life trigger after some sub-population of cells has been set up is disquieting, but I do think those models might actually provide some insight into that as well.”

“Meetings of the consortium of laboratories that are working on mouse models I believe is very valuable and almost essential and I would argue that the various commercial entities that are attempting to enter the FSHD therapeutics space should be involved in attendance and I would argue support at least the meetings of the consortium if nothing else, because I think this is a very simple way in which the therapeutic development can (a) be accelerated, and (b) to some extent, de-risk or lower the risk.”

V. Therapeutic studies

Clinical trials are on the horizon, meaning that the community needs to be prepared (clinical trial preparedness).

FSHD models need to be available to address drug delivery and efficacy in preclinical trials.

For clinical trial preparedness registries need to be assembled and harmonized.

“In addition to testing our compounds, though, some models that really recapitulate the disease in their progression can give us insight into when we might consider treating, how early in the course of the disease we may need to treat in order to see the changes that we like to drive into the clinic. The other information it might give us is the duration of treatment that may be required to impact the disease. So if you were to have a model that recapitulates the course of the disease relatively accurately, using the endogenous gene and potentially even using the endogenous locus regulation region, that could be highly valuable in understanding not just how much to treat with, the dose, but the duration, and the time of initiation.”

“Precisely how you deliver, how you formulate, how you get the conceptual entity to the effective therapeutic use of the entity requires something that you can test. Now even Need to address formulation and delivery issues and half life issue, PK, PD, all that stuff. You can do some of that in normal animals, but it really begs the question if the delivery to an affected tissue is different from the delivery to a normal tissue and that, for example, might be relevant, let’s say, in the muscular dystrophies we know some of the issues in delivery to Duchenne muscle and that’s been an issue, I think, in some of this clinical work that’s been done. So I agree with you completely, we have to think about and have ready thoughtful understanding of how we’re going to develop both understanding of delivery modalities and understand PK and PD and everything else about the use of a therapeutic intervention, whatever it is.”

VI. Workshops

Ideas for workshops that came up during parts of the discussion (no specific ranking).

Workshop 1 — Mouse models consortia/meeting powered by industry.

Workshop 2 — Uniformity in the genetic testing as so far as that is possible (the establishment of a central equivalent of WADA for the Olympics or something like that where, done under uniform conditions).

Workshop 3 — The subgrouping of patients (a further understanding of the epigenetic regulation of the repeats helps us to better understand the disease process and the disease mechanism).

Workshop 4 — Surrogate outcome biomarkers.

Research Priorities for 2015

I. Genetics. The vast majority of clinically diagnosed FSHD patients can be genetically classified as FSHD1, due to D4Z4 repeat contraction on chromosome 4, or FSHD2, due to mutations in the SMCHD1 gene on chromosome 18. Other forms of FSHD2 may also exist as <15% of FSHD2 cases cannot be explained by SMCHD1 mutations. Both forms converge to a common molecular pathway characterized by D4Z4 repeat chromatin relaxation and DUX4 expression in amongst other muscle. It was discussed as to whether this is the operational definition of FSHD and a consensus arrived at. It was agreed on that there are rare FSHD-syndromes possibly without these epigenetic and molecular hallmarks and that maybe caused by other genes and mechanisms – it is known that mutations in various muscular dystrophy genes can yield FSHD-like symptoms. It was considered important to collect and carefully characterize these patients clinically and genetically. Samples could be handled by the U.S. NIH Wellstone and Fields Centers. To facilitate access to information on FSHD mutations, it was recommended to submit data to the Leiden Open Variation Database (LOVD) mutation database, hosted by Leiden (curator Dr. Richard Lemmers). The options to include relevant clinical data will be explored.

II. Mechanisms and targets. The discussion focused on the mechanism of DUX4 expression (bursts), including up-and downstream steps. Although there is much evidence for stochastic expression bursts of various genes, (muscle-specific) factors may specifically facilitate bursts of DUX4 in adult muscle – normally expressed only in embryonic tissue. The significance of DUX4-inducedlink with apoptosis is not understood, though it has been shown that the RNA (and protein) spreads to multiple nuclei in the same fiber. Why FSHD preferentially affects skeletal muscle, whether reflecting the DUX4 expression or toxicity, is particularly toxic in muscle is poorly understood and in need of further work as it might reveal interesting intervention targets.

III. Models. During the past several years, various models have been generated, most of them focusing on DUX4. In the past year, the most intriguing ones are:

The long-awaited inducible mouse model. No muscle phenotype was detected before these juvenile animals die. However, a defect in regeneration was demonstrated when muscle stem cells from these animals were transplanted. This model may be useful for testing in vivo activity of anti-DUX4 therapeutics.

Various virus viral delivery-based models have been reported. Depending on amongst other the delivery system, these models can produce burst-like expression patterns of small numbers of myonuclei expressing DUX4.

Two labs reported on the generation of stem cells, embryonic and induced ones. Although in an early stage, this approach might prove very interesting also for fundamental studies on DUX4 and chromatin structure.

IV. Patients – trial preparedness. For FSHD phenocopies (non-D4Z4 or SMCHD1 mutated) all agreed that differential diagnosis has to be ruled out (by muscle biopsy and genetics) and it was advised to put these cases in an international repository. On trial readiness the audience suggested to reach for a worldwide agreement on a severity score and a standpoint on the FSH-com and a patient reported outcome in order to be able to compare clinical trials more easily. Other suggestions that were briefly discussed:

To study which methylation assay would separate best patients from controls.

The need for more groups to study biomarkers in order to select the best ones for follow-up of patients.

More studies on Electrical Impedence Myography (EIM) are needed to find the shortest time interval to demonstrate significant changes in muscles.

Integration of MRI in the clinical discussions of FSHD.

Background
These priorities were developed at the 2014 FSHD International Research Consortium and Research Planning meetings. Close to 80 scientists, patients, advocates, biotech and pharmaceutical companies, and clinicians from throughout the world gathered at a satellite meeting of the Annual Meeting of the American Society of Human Genetics in San Diego on October 17-18, 2014, sharing their latest progress in facioscapulohumeral muscular dystrophy (FSHD) research at the 2014 FSHD International Research Consortium and Research Planning meetings. The Meeting was chaired by Dr. Michael Altherr (Los Alamos National Laboratory, Los Alamos, New Mexico), Dr. Stephen Tapscott (Fred Hutchinson Cancer Research Center, Seattle, Washington) and Dr. Silvère van der Maarel (Leiden University Medical Center, Leiden, the Netherlands and co-PI of the Fields Center for FSHD and Neuromuscular Research). David Housman, MIT, Cambridge, Massachusetts and Daniel Perez, President & CEO of the FSH Society, Lexington, Massachusetts served as the organizational chairs.

The goal of this meeting was to integrate clinical and basic FSHD research, explore and verify the complex disease mechanism and various features of FSHD, and to follow up on considerations to move into the development of potential treatments for FSHD. Other research directors attending the meeting were Greg Block of PNW Friends FSH, Seattle, Washington, Mr. Kees van der Graaf represented the Dutch FSHD Foundation and FSHD Europe, Mr. Patrick Cameron of FSHD Global Research of Australia, Mr. Neil Carmata of FSHD Canada, Mr. Christopher Carrino and Mr. Chris Hughes of the Chris Carrino Foundation for FSHD, and Andrew Graham, MD Campaign, UK. All volunteer agencies working on FSHD were invited by the organizers and encouraged to attend. The FSH Society was represented by Dr. Michael Altherr, Mrs. June Kinoshita and Mr. Bill Lewis, Sr., Dr. Louis Kunkel, Dr. Rune Frants and Dr. George Padberg. Sponsors for the research workshop included: aTyr Pharma, Association Française Contre les Myopathies (AFM), Cytokinetics, FSHD Canada, FSH Society, FSHD Global Research Foundation, Genzyme, a Sanofi Company, Muscular Dystrophy Association United States (MDAUSA), and NIH Eunice Kennedy Shriver NICHD Senator Paul D. Wellstone MDCRC for FSHD at University of Massachusetts Medical School.

After a brief welcome by the organizers including an overview of last years’ priorities and the follow up on these priorities by the FSHD community in 2013. There was a general consensus that, based on the publications that have appeared in the past year, there had been an impressive response to the priorities formulated during the 2013 meeting. The overview was followed by a series platform sessions reviewing the latest advancements in (1) clinical studies, (2) genetics and epigenetics, (3) molecular mechanisms, (4) models, and (5) therapeutic studies. Each platform session included presentations from several speakers selected from the pre-submitted abstracts. Sufficient time was allowed after each of platform sessions each moderated by two distinguished scientists whose role was to provide a stimulating overview of the topic and facilitate discussion. During the breaks there was ample time to review and further discuss the latest developments at the posters. The meeting was a working meeting with experts, developing future plans in the context of what we know now. It was a very successful workshop with a positive, constructive and collaborative atmosphere where new and unpublished findings were communicated to the audience, and with excellent interaction between all participants.

The second day was solely dedicated to the Discussion and Planning Session, included several sessions chaired and moderated by Drs. Altherr, Frants, Tapscott, Van der Maarel, and Padberg. From these discussions the following conclusions were made and priorities were defined.

Research Priorities for 2014

Brief Summary of Priorities and General Discussion, Tuesday October 22, 2013

DUX4. The unanimous conclusion of the general discussion was that overexpression of the toxic transcription factor Dux4 is at the root of FSHD1 and FSHD2. Expression of flDUX4 mRNA (and protein) is dependent on two conditions: 1. A specific DUX4 haplotype containing a poly-A site and 2. An open chromatin structure, due to D4Z4 repeat contraction-dependent (FSHD1) or contraction-independent (FSHD2) mechanisms, the latter due to mutations in the SMCHD1 gene encoding a chromatin modulating enzyme. There are indications for further genetic heterogeneity, thus additional gene defects causing FSHD. The chromatin relaxation of the DUX4 region (close to the #4q telomere) can induce additional gene expression effects in cis (#4) and trans (other chromosomes). As Dux4 is a transcription factor, the over-expression can trigger a cascade of downstream molecular pathways contributing to the large variability in the clinical phenotype and natural history of FSHD. Conclusion: DUX4 expression is necessary but not always sufficient to cause FSHD. Research should focus on upstream and downstream molecular pathways and mechanisms as they form the most plausible intervention targets.

Disease models. The field needs improved and specific in vivo (animal) models for mechanistic and intervention studies. At this stage it is not sensible to give strict recommendations. Inducible (conditional) models seem necessary to dissect spatial and temporal effects of the DUX4 pathway. For specific questions, simpler models, like zebra fish may have unique potential. Various xenograph models aiming at generating human muscle in mouse muscle are promising, but strongly dependent on availability of human muscle biopsies or cell lines. In other muscle disease fields, AAV mediated “gene therapy” has proven its value. Availability of higher vertebrate models (e.g. dog, primates, etc.) may be helpful to study intervention effects prior to human trials.

Intervention. Is there a magic bullet for FSHD treatment? Although the DUX4 over expression is crucial, various biological and chemical (pharma) strategies can be envisaged to intervene with the overall expression mechanism, directly by targeting the mRNA or the protein, or indirectly by modulating the transcription machinery, including the chromatin structure. As the ultimate goal is to influence the clinical phenotype and disease progression, intervention in specific molecular subpathways of the DUX4 cascade may form alternative strategies.

Clinical studies and trial readiness. There is an urgent need for better understanding of the natural history of FSHD, for example, the clinical heterogeneity between and within families, the asymmetric expression of the disease, the cause and consequence of inflammation, and the effect of physical and cognitive training etc. The FSHD field is working hard to establish patient databases with detailed clinical and genetic information. Equally, the development of sensitive quantitative clinical monitoring methods to follow intervention trials has a high priority. It is important to closely follow the situation in related fields, for example, Duchenne, etc.

Priorities for 2014

The DUX4 interactome

Understanding DUX4 manifestation and variation

Additional genetic heterogeneity; non-FSHD1 and 2

Disease models

Well documented Natural history with reliable endpoints; modulating mechanisms/genes

Evidence continues to accumulate suggesting that the mal expression of DUX4 is a trigger leading to a pathologic cascade culminating in FSHD disease.

Current theory indicates that the majority of FSHD cases results from a genomic contraction of a DUX4-containing DNA repeat near the terminus of the long arm of chromosome 4. Furthermore, this contraction provides a transcriptionally permissive chromatin environment, which coupled with a DNA polymorphism that produces a functional polyadenylation site immediately adjacent to the final copy, allows and creates a stable DUX4 transcript that produces a protein with potent deleterious properties. The impact of an exceedingly small amount of a molecule like DUX4 to initiate such a devastating pathological cascade is going to be a significant therapeutic challenge likely requiring a multi-pronged approach to ameliorate the consequences of the disease cascade. However, the association of a small highly specific DNA polymorphism that leads to a distinct phenotype (in this case, FSHD disease) is reminiscent of a classic dominant gain-of-function mutant. Moreover, if theory is correct, the specific disruption of the site that gives rise to the polyadenylation signal should prevent the translation of the DUX4 protein and eliminate it as the trigger of the pathological cascade that gives rise to FSHD. Recently, a number of techniques have emerged that allow the targeted “engineering” of specific sites in the genome (e.g., TALEN and CRISPR).

The FSH Society would be interested in seeing proposals using genomic engineering techniques that specifically target the DUX4 gene and include an assessment on the impact of these types of DUX4 manipulations on one or more phenotypic measures.

Mechanism of Support: Up to $125,000 in funding is available for one year. Smaller and larger budgets will be considered if accompanied by adequate justification. Applications may be submitted by non-profit academic institutions and for-profit organizations, worldwide.

The deadline date for our current grant review cycle is August 31, 2013. Submission of a Letter of Intent (LOI) is required prior to August 15, 2013, sent to daniel.perez@fshsociety.org.

The full Application form can be downloaded here: https://www.fshsociety.org/assets/pdf/FSHGrantAoplication2012.pdf

The FSH Society supports research that can lead to a better understanding of the pathological mechanisms that give rise to FSH dystrophy, and might ultimately lead to an understanding that could lead to therapeutic interventions.

Evidence continues to accumulate suggesting that the ectopic expression of DUX4 is a trigger leading to a pathologic cascade culminating in FSHD disease. Current theory indicates that the majority of FSHD cases results from a hypomethylation-associated chromatin relaxation of DUX4-containing DNA repeats near the terminus of the long arm of chromosome 4. The more common form, FSHD1, is caused by a genomic contraction of the D4Z4 repeat array, while FSHD2 is caused by a contraction-independent hypomethylation. These genomic modulations provide a transcriptionally permissive chromatin environment that coupled with a DNA polymorphism produces a functional polyadenylation site immediately adjacent to the final copy and creates a stable DUX4 transcript that produces a protein hypothesized to have potent deleterious properties.

The FSH Society is especially interested in research proposals aimed at elucidating the pathogenic cascade that results in muscle destruction in FSHD. High priority will be given to applications that are suitably powered, involve cross-sector or interdisciplinary collaborations, or explore truly novel ideas. Priority Areas for the Request for Proposals include:

Understanding the pathophysiology of FSHD muscle degeneration, from early onset to loss of function.

Robust model systems of disease pathogenesis.

Identification of disease-modifying genes in FSHD.

Identification of events that trigger the onset of FSHD muscle degeneration.

Access to FSHD samples: The FSH Society can facilitate access to patient specimens, including blood and primary muscle tissue collected from 42 family cohorts with over 100 individuals, situated at the Senator Paul Wellstone Centers for FSHD Research.

Mechanism of Support: Up to $125,000 in funding is available for up to two years. Smaller and larger budgets will be considered if accompanied by adequate justification.

Applications may be submitted by non-profit academic institutions and for-profit organizations, worldwide. The deadline date for applications is August 31, 2013.

Research Priorities for 2013 and Beyond

Priorities as Stated by FSHD Research Community for FSHD Research: 2013 and Beyond at the International Research Consortium meeting in November 2012

The summary and recommendations of the group state that given the recent developments in our definition of FSHD1A and FSHD1B [FSHD2] and there is a need to ramp up the preclinical enterprise and build/organize infrastructure needed to conduct clinical trials on FSHD1A and FSHD1B. Our immediate priorities should be to confirm the DUX4-fl hypothesis, if valid then understand normal DUX4 function, and finally, understanding the naturally occurring variability should allow us to manipulate the disease in our favor. We need to be prepared for this new era in the science of FSHD, by accelerating efforts in the following five areas:

Genetics/epigenetics. There is general acceptance that transcriptional deregulation of D4Z4 is central to FSHD1 and FSHD2. The FSHD2 gene SMCHD1 explains approximately 80% of FSHD2. There is a need for better understanding of the factors that modulate DUX4 activity and disease penetrance.

FSHD molecular networks. D4Z4 chromatin relaxation on FSHD-permissive chromosome-4 haplotypes leads to activation of downstream molecular networks. In addition to considering DUX4 as the “target” and downstream targets, the upstream processes and targets—triggering of activation—are equally important. Hence, understanding what DUX4lf does as a target and targets up- and down-stream of it are priorities. Detailed studies on these processes are crucial for insight in the molecular mechanisms of FSHD pathogenesis and may contribute to explaining the large intra- and interfamily clinical variability. Importantly such work may lead to intervention (possibly also prevention) targets. Additional FSHD genes and modifiers are still likely to exist. Apart from chromatin modifiers, these include, but are not limited to, CAPN3 and the FAT1 gene that was recently suggested to be involved in FSHD.

Clinical trial readiness. It is now broadly accepted that deregulation of the expression of D4Z4 / DUX4 is at the heart of FSHD1 and FSHD2. This finding opens perspectives for intervention along different avenues. Intervention trials are envisaged within the next several years. The FSHD field needs to be prepared for this crucial step. There is an increasing need to improve the translational process. This includes, but is not limited to, the need for consensus on data capture and storage, overcoming national and international barriers, definition of natural history, identification of (meaningful) and sensitive outcome measures, biomarkers, and meaningful functional measures. There is a need to work more closely with FDA to help define acceptable measures for trials.

Model systems. There was already a good set of cellular and models, based on different pathogenic (candidate gene) hypotheses. This was further expanded during the last year. The phenotypes are very diverse and often difficult to compare with the human FSHD phenotype. Many basic questions remain unanswered and dearly need to be answered for further translational studies: when and where is DUX4 expressed in skeletal muscle and what regulates DUX4 activity. It was recognized that there still exists a gap in our knowledge linking the basic genetic and molecular findings with the observed muscle pathology. The BBRI NIH Sen. Wellstone center and the Fields Center continue to generate human cellular resources. These resources continuously deserve attention and need to be replenished. Recent progress in ES-cell technology, including iPS lines, allows for inter-group distribution and dedicated molecular (epi)genetic studies.

Sharing. Timely sharing of information and resources remains a critical contributor to the progress in the field. Wellstone and Fields Center continue to share their resources to the scientific community. The Fields Center website also continues to share other information (e.g. protocols, guide to FSHD muscle pathology, etc.). We thank you for your financial support of the FSH Society FSHD International Research Consortium Workshop to help foster significant progress in both collaboration on FSHD and our understanding and treating FSHD.

Research Priorities for 2012

Priorities as Stated by FSHD Research Community for FSHD Research: 2012 and Beyond

The international FSHD clinical and research community recently came together at the DHHS NIH NICHD Boston Biomedical Research Institute Senator Paul D. Wellstone MD CRC for FSHD. Almost 90 scientists working on FSHD globally met at the 2011 FSH Society FSHD International Research Consortium, held November 7-8, 2011.

The summary and recommendations of the group state that given the recent developments in our definition of FSHD and the potential that within one to two (1-2) years, evidence-based intervention strategies, therapeutics, and trials being planned and conducted. Our immediate priorities should be to confirm the DUX4 hypothesis, if valid then understand normal DUX4 function, and finally, understanding the naturally occurring variability should allow us to manipulate the disease in our favor. We need to be prepared for this new era in the science of FSHD, by accelerating efforts in the following four areas:

Genetics/epigenetics. It is now broadly accepted that disregulation of the expression of D4Z4 / DUX4 is at the heart of FSHD1 and FSHD2. Additional FSHD (modifier) loci are likely to exist. FSHD molecular networks. The relaxation of the chromatin structure on permissive #4 haplotypes leads to activation of downstream molecular networks. Importantly, the upstream processes—triggering of activation—are equally important. Detailed studies on these processes are crucial for insight in the molecular mechanisms of FSHD pathogenesis and may contribute to explaining the large intra- and interfamily clinical variability. Importantly such work may lead to intervention (possibly also prevention) targets. Additional FSHD genes. FSHD2 is characterized by hypomethylation of D4Z4 on #4 as well as #10. This also leads to bursts of DUX4 expression. Identification of the responsible factor (gene) and molecular mechanisms is of utmost importance. This work will be facilitated by the recruitment of additional families. Also other genes need to be considered that may give rise to FSHD-like phenotypes. These include, but are not limited to, CAPN3 and the FAT1 gene that was recently suggested to be involved in FSHD.

Clinical trial readiness. It is now broadly accepted that disregulation of the expression of D4Z4 / DUX4 is at the heart of FSHD1 and FSHD2. This finding opens perspectives for intervention along different avenues. Clinical Trial Readiness. Intervention trials are envisaged within the next several years. The FSHD field needs to be prepared for this crucial step. To design and coordinate this important translational process, it was envisaged to install an international task force Clinical Trial Readiness (FSHD-CTR), with Dr Rabi Tawil as leader. The FSHD-CTR needs to be a multidisciplinary group, including members with expertise, not only in FSHD but also, in trial design and execution, statistics, (non-invasive) biomarkers etc. Important issues are: Natural history Homogeneous clinical criteria Biobanks, biomarkers etc. Reliable outcome measures Patient registries Biomarkers. Sensitive biomarkers are needed to monitor intervention: they might also improve diagnosis. Important to consider biomarkers established from easily accessible sources like blood. Non-invasive methods like imaging needs further attention. Quantitative muscle function methods are instrumental as are patient-reported indicators.

Model systems. There are a plethora of cellular and models, based on different pathogenic (candidate gene) hypotheses. Moreover, the phenotypes are very diverse and often difficult to compare with the human FSHD phenotype. FSHD Model Data Base. The importance of a systematic database was recognized. This DB should contain detailed information on the molecular characteristics of the model (design and phenotype). Particular emphasis should be paid to the muscle pathology. Non-muscle phenotypes – described also in FSHD patients deserves attention. Human pathology and bio-banking. Importantly, this DB should also contain well-documented muscle pathology data of patients – astonishingly difficult to find in the literature. Human cellular resources continuously deserve attention. Recent progress in ES-cell technology, including iPS lines, allows for inter-group distribution and dedicated molecular (epi)genetic studies.

Sharing. Timely sharing of information and resources remains a critical contributor to the progress in the field. There are several initiatives that create large repositories of data and resources, e.g. Wellstone and Fields Center. Their websites should be used for sharing of information (e.g. protocols, guide to FSHD muscle pathology (images), model systems, contact information), reagents, and resources.